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Semester 3 PID Exam 4 > Coding > Flashcards

Coding Flashcards

1
Q

Coding

A

Description of disease, injures, symptoms and healthcare procedures that are put into numeric and alphanumeric designations

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2
Q

Why do we use codes

A

Universal codes assist with clinical care, research and education
Reporting for reimbursement
Help with administrative functions
Direct surveillance of epidemic or pandemic outbreaks

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3
Q

Difference between ICD-10-CM and ICD-10-PCS

A

CM = clinical modification
Used for outpatient
PCS = procedure coding system
Used for inpatient

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4
Q

Benefits of ICD-10-CM for PT

A 
Greater detail 
Laterality
Trauma vs. non
Cause of injury
Dominant side vs. non
Single vs bilateral
Type of encounter
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5
Q

ICD 10 code structure

A

1st = capital letter
2nd = number
3rd = alpha or numeric
All will have at least three

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6
Q

Structure and Format - ICD 10

A

Alphabetical Index = first step

Tabular list = second for cross reference

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7
Q

ICD 10 - Alphabetical Index

A

INdex of disease and injury, external causes of injury, tables of neoplasms, drugs, and chemicals
Reference the specific condition, disease, sign or symptom in alphabetical index

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8
Q

ICD 10 - Tabular list

A

Chapters based on body system or condition

Check for instructional notes regarding exclusions and/or additional characters required for a valid code

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9
Q

Coding for laterality

A 
0 = unspecified
1 = right
2 = left
3 = bilateral
Make sure to cross reference though
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10
Q

Injury code doesnt usually have bilateral - then what?

A

you would code L and R

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11
Q

Placeholder purpose

A

Allows for future expansion within the code

If a code has less than 6 characters and a 7th is required, then you use placeholders

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12
Q

7th characters are used for

A

Injuries or other consequences of external causes

Used to describe the type of encounter

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13
Q

7th Character - options

A 
A = initial encounter
D = subsequent encounter
S = sequela
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14
Q

Excludes 1 Code

A

Should not report the codes listed when you report the above codes

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15
Q

Excludes 2 codes

A

These conditions can be on the claim form on the same day you report the above codes

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16
Q

Documentation

A

Function
Medical Necessity
Support the skills of a qualified therapist
Continued need for therapy
Use physician referral and clinical assessment documentation
Must be specific and relevant to the problem being treated

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17
Q

Medical necessity - interventions should be

A

Complex enough to require a PT
Provided by or under direction of PT
Amount, frequency and duration must be reasonable and necessary for diagnosis
Intervention plan/goals described in detail and focus upon function
Supported by evidence
Documentation to support services
Patient must show progress or dec risk of further progression of a condition

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18
Q

ICD-10 documentation

A

Specificity and severity of condition
Other underlying/complicating conditions that may impact prognosis
Support for reported quality data
Support for medical necessity required for coverage in payer policies
Diagnosis must match referring physicians code
4 diagnosis codes per procedure code allowed

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19
Q

PT documentation tips

A

First listed condition should be primary reason for PT visit
Must be specific

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20
Q

ICD-10 impact on CPT codes

A

ICD 10 does NOT change any of the CPT codes or HCPCS level II codes used for outpatient

21
Q

HCPCS level II for durable medical equipment

A

Medical equipment to assist in function and improved quality of life (wheelchair, walker, shower chair)
Certificate of medical necessity
Approved DME provider

22
Q

HCPCS level I - CPT codes

A

HCPCS level I codes is a set of procedure codes based on AMA Current procedural terminology (CPT)

23
Q

CPT - physical medicine and rehab codes begin with

A

97001
Some codes are service based and some are time based
Some codes require different level so of supervision

24
Q

Untimed CPT codes

A

CPT codes where the procedure is not defined by the timeframe
Only one unit is billed on the same day
Performed by PT or PTA
Eval, Re-eval, Traction, Paraffin

25
Q

CPT Timed codes

A

Direct one on one time spent in patient contact
Require constant attendance
Based on 15 min unit of service
Performed by PT or PTA
US, ther ex, neuro re-ed, gait, manual ther, therapeutic activity

26
Q

8 minute rule for timed CPT codes

A

Time based units are in 15 minute increments
Time must be greater than 8 min
Total number of units constrained by total time with patient for the day (Medicare)

27
Q

8 minute rule - impacted by total time - 1 unit =

A

8-22 min

28
Q

8 minute rule - impacted by total time - 2 units =

A

23-37 min

29
Q

8 minute rule - impacted by total time - 3 units =

A

38-52 minutes

30
Q

8 minute rule - impacted by total time - 4 units =

A

53-67 minutes

31
Q

8 minute rule - impacted by total time - 5 units =

A

68-82 minutes

32
Q

8 minute rule - impacted by total time - 6 units =

A

83-97 minutes

33
Q

Delivery of exercise - Therapeutic Procedure

A

97110
1:1 treatment with PTA/PT
Constant attendance with patient
Timed code

34
Q

Delivery of exercise - Group therapy

A

97510
More than 2 patients simultaneously with PT or PTA
Constant attendance with patients but they dont have to be performing the same exercise

35
Q

What if individual attn while doing group therapy

A

you can bill with a 59 modifier

36
Q

Bundled codes

A

These codes are part of other codes and cannot be billed separately with CMS

37
Q

Examples of bundled codes

A

Hot/cold pack
Phonophoresis - can bill US but not separately for meds
Wound care - cant bill separately for bandages
Iontophoresis - cant bill separately for meds
E Stim - cant bill separately for electrodes

38
Q

Correct coding initiative (CCI edits)

A

Promote correct coding and ensure appropriate payments

39
Q

Modifiers - what are they

A

2 digit codes that tells the payer to pay for something that they usually wouldnt

40
Q

59 modifier

A

2 similar procedures performed on same day on same individual

41
Q

KX modifier

A

Therapy cap was met but medically necessary for further treatment

42
Q

GP modifier

A

Code for PT providing the therapy

43
Q

Multiple Procedure Payment Reduction (MPPR)

A

The highest reimbursed code is paid at 100% - the subsequent codes are reduced

44
Q

Fraud

A

Intentional misrepresentation or deception

45
Q

Abuse

A

No intent to deceive or misrepresent

46
Q

Examples of abuse

A 
Upcoding
Downcoding
Unbundling procedures
Charging for services not performed 
Lack of medical necessity
47
Q

Compliance

A

Voluntary programs to combat fraud and abuse

48
Q

Audits

A

Conducted to be sure billing is accurate

49
Q

Proposed changes for CPT eval coding structure

A

3 levels of eval complexity - low, med and high

Right now is fee for service

Semester 3 PID Exam 4 (3 decks)

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